Massive Left Pleural Effusion Research Articles

Primary pancreatic Ewing sarcoma with metastases on FDG PET/CT

BackgroundEwing sarcoma (ES) is a highly aggressive malignant tumor most commonly affecting long bones. Extraskeletal Ewing sarcoma (EES) is a malignant tumor with aggressive behavior carrying bad prognosis with pancreas being an extremely rare primary site. We present a case of histopathologically proven EES of the pancreas in a young female who presented with abdominal pain. 18F-fluorodeoxyglucose positron emission tomography (18F FDG PET/CT) is a useful modality for detecting distant metastases in EES. It helps in diagnosis, localizing the primary, its extension, optimal treatment planning and evaluation of response to standard treatments available.Case presentationAn 18-year-old female presented with complaints of progressive abdominal pain and distention since 6 weeks. Physical examination was suggestive of a solid large mass in the upper left abdomen and decreased breath sounds with dullness in the left lower lung fields. On Contrast enhanced computed tomography (CECT) imaging, a large heterogeneously enhancing mass was seen arising from pancreas along with retroperitoneal lymphadenopathy. A moderate sized left sided pleural effusion with atelectasis of lower lobe of left lung was also noted. Histopathological analysis was suggestive of pancreatic ES following which the patient underwent five cycles of chemotherapy. Following this, she underwent 18F FDG PET/CT which showed hypermetabolic large mass arising from body and tail of pancreas with areas of internal necrosis along with left adrenal metastasis, retroperitoneal lymphadenopathy, a massive left pleural effusion and compressive atelectasis of left lower lobe. The patient expired within a week following PET/CT.ConclusionsEES most often presents in the late stage of the disease with vague symptoms. Timely diagnosis and initiation of treatment is of utmost importance considering the aggressiveness of the tumor. Establishing a diagnosis of Ewing sarcoma is especially difficult when the mass is arising from the pancreas. Imaging, histopathology and immunohistochemistry (IHC) play a key role in accurate diagnosis of such masses. 18F FDG PET/CT can be useful for detecting local and distant spread, operability, treatment planning and evaluation of response to chemotherapy.

Massive pleural effusion, what should we do in emergency department? a case report

Indonesia has been known as an endemic country of tuberculosis (TB). Most of the cases are pulmonary TB, and pleural effusion is one of the common cases. Untreated pleural effusion can become massive pleural effusion, a true emergency case in the emergency room. In this report we present a 21-years-old female patient with new onset massive pleural effusion due to TB infection. A 21-year-old female patient with no previous medical illness came to ER with shortness of breaths since a week ago. Cough and unmeasured fever have been reported since a month ago. Tachypnea, extreme tachycardia, asymmetric chest movement, decreased vocal fremitus, dullness of percussion, and decreased left pulmonary sound were found. Chest x-ray showed a massive left pleural effusion with tracheal deviation. High flow nasal cannula was given due to blood gas analysis interpreting moderate respiratory distress. Thoracentesis was immediately performed with estimated 1200 CC yellow coloured fluid production. Other laboratory findings include hyponatremia and hypoalbuminemia. This patient was diagnosed with pleural effusion type pulmonary TB, treated with anti-TB drugs, mucolytic, corticosteroid, and analgesics. Serial chest x-rays showed improvement of pleural effusion. In developing countries like Indonesia, the most common causes of pleural effusion was TB infection besides malignancy. A massive pleural effusion diagnosis can be established with history taking, physical examination, chest sonography, chest x-ray, and/or CT-scan. Thoracentesis must be performed within minutes after massive pleural effusion was established.

An Elusive Case of Pleural Effusion

The incidence of distant metastasis in head and neck Squamous Cell Carcinoma (SCC) is relatively low. The most frequently involved sites for distant metastasis are lungs, followed by bone and liver. The most important predictive factors for distant metastasis appear to be site of the primary tumour (hypopharynx), advanced T- and N-classification, locoregional control and histologic grade. A 61- year-old male, chronic smoker, presented with complaints of grade 4 mMRC (Modified Medical Research Council) dyspnoea. He had left-sided buccal mucosal SCC (locally advanced) and was on palliative chemotherapy. He had undergone treatment for pulmonary tuberculosis seven years back. He was tachypneic and clinical examination revealed absent breath sounds in the left hemithorax. Chest radiograph showed a massive left pleural effusion which was found to be exudative after therapeutic thoracocentesis. Cytology tests were negative for malignant cells. Positron Emission Tomography (PET) scan showed uptake along the left pleura (SUV Max-5.06) and left buccal mucosa (SUV Max -4.1). Thoracoscopic frozen section pleural biopsy revealed metastatic squamous cell carcinomatous deposits in the pleura. On table pleurodesis was done with doxycycline. The patient was continued on palliation with no recurrent effusion. However, he succumbed to the disease after eight months. This case report describes a rare case of malignant pleural effusion from a primary buccal mucosal SCC without any concurrent lung involvement.

Autopsy case of a patient with rapidly progressive combined small‐cell lung carcinoma with spindle‐shaped cell tumor

A 69‐year‐old Japanese man visited our hospital because of worsening shortness of breath. His chest computed tomography (CT) showed a giant left lung mass with a massive left pleural effusion. He could not be treated with chemotherapy and eventually died from a rapidly progressive tumor. He was diagnosed with combined small cell lung carcinoma (C‐SCLC) with spindle‐shaped cell tumor at autopsy. C‐SCLC is characterized by pathologically concurrent SCLC and adenocarcinoma or squamous cell carcinoma, or rarely, spindle‐shaped cell tumor. The clinical course of C‐SCLC with spindle‐shaped cell tumor has not previously been determined. Our patient's tumor increased by 2.59‐fold in 20 days. The combination of C‐SCLC with spindle‐shaped cell tumor suggested rapid progression and a poor prognosis.

Case Report: 43-years old-Male with Pulmonary Sequestration which Mimics Lung Tumor and Aspergillosis

Background: Pulmonary sequestration is a very rare congenital abnormality of the lung, which was responsible for 0.15-6.4% of all cases of congenital lung formation disorders. Pulmonary sequestration is often seen as recurrent pneumonia, accompanied by complaints of chest pain, shortness of breath and hemoptysis. Conventional angiography is the gold standard for diagnosing pulmonary sequestration and for demonstrating arterial supply and venous drainage. The optimal therapy for pulmonary sequestration is operative resection to avoid infection and damage to the lung parenchyma. Case Report: We reported a case of 43-years old-male with pulmonary sequestration, previously diagnosed with a lung tumor with massive left pleural effusion and pneumonia. A series of diagnostic tests found no malignant cells. During FNAB with CT scan guiding, we found an image of a fungus ball, thus, he was diagnosed with Aspergillosis. The patient was planned to undergo VATS. There were complications during the operation, thus, a lobectomy with an open thoracotomy was performed, and an arterial anomaly was found from the abdominal aorta. The operation was successful and the patient was able to carry on with his normal activities.Conclusion: Establishing a definite diagnosis of pulmonary sequestration is very difficult, and in this case, it was done through lobectomy with thoracotomy and through a multidisciplinary approach.

COVID-19 MANIFESTATION IN A CHILD WITH LUNG METASTASES OF OSTEOSARCOMA: A CASE REPORT

Background: COVID-19 (Corona virus disease-19) is an infectious disease caused by a new type of corona virus which in the same group of the virus that causes Severe Acute Respiratory Syndrome (SARS), where the incubation period for infection is 1-14 days or up to 24 days, accompanied by symptoms of a respiratory tract infection and other organ systems. The number of recent cases in November 2020 was 59.8 million worldwide. Elderly patients and people with comorbid diseases are at high risk of developing severe manifestations of this viral infection. Osteosarcoma is a deadly bone cancer that often causes patients to die from metastases to the lungs Purpose: The purpose of this study is to report cases of COVID-19 in a 9-year old child patient with a history of osteosarcoma at Bethesda Hospital Yogyakarta. Case Description: A 9-year old female patient came to the emergency room complaining of fever, cough, severe chest pain, and shortness of breath since 3 weeks before being admitted to the hospital. The patient had a past medical history of osteosarcoma since 1.5 years before being admitted to the hospital and an amputation procedure on the right arm was carried out, no specific illness in the family history was found. The general condition of the patient appears to be moderate with delirium consciousness (E4V6M1). Vital sign examination showed a pulse rate of 130 beats per minute, an oxygen saturation of 85% and a breath rate of 30 beats per minute. CT scan without contrast shows a massive left pleural effusion, malignancy/metastatic mass of the left lung, with pneumonic opacity in the right lung. Conclusion: COVID-19 is an infectious disease caused by SARS-CoV-2 and causes severe manifestations in patients with comorbid diseases including pulmonary metastases. CT-Scan modalities are used as a basis for diagnosis other than RT-PCR. Management of COVID-19 is in the form of supportive therapy based on the degree of disease severity.

Massive hemothorax in a pregnant patient with neurofibromatosis type 1

BackgroundReports of spontaneous hemothorax in patients with neurofibromatosis type 1 are scarce despite the severe complication. We herein present the first case of hemothorax in a neurofibromatosis type 1 patient during pregnancy and discuss the difficulty associated with its diagnosis and treatment.Case presentationA 39-year-old female at 34 weeks gestation presented with sudden left back pain and dyspnea. Chest radiography revealed massive left pleural effusion. Computed tomography showed bleeding from the intercostal artery. Although the patient appeared hemodynamically stable, the fetus was in a critical condition. Emergency caesarean section was performed within 1 hour. Subsequently, we performed endovascular coil embolization of the intercostal artery. While this intensive treatment saved the patient, her fetus could not be rescued.ConclusionsPatients with neurofibromatosis type 1 may develop massive hemothorax without gross lesions. In late pregnancy, sufficient infusion and quick hemostasis are essential and can be lifesaving.

A RARE CASE OF EMPYEMA SECONDARY TO PANCREATICOPLEURAL FISTULA

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pancreaticopleural fistula is a rare complication of pancreatitis resulting from pancreatic duct disruption with leakage of pancreatic secretions into the pleural cavity. CASE PRESENTATION: 50-year-old woman with alcohol use disorder and chronic pancreatitis presented with abdominal pain, vomiting and dyspnea on exertion. Serum chemistries revealed elevated lipase and amylase suggesting acute pancreatitis. Computer Tomography (CT) chest, abdomen and pelvis revealed massive left pleural effusion causing mediastinal shift to the right and multiple rim-enhancing cystic structures around the pancreas, suggestive of pancreatic pseudocysts. Pleural drainage was performed with a chest tube placement, after which patient reported symptom relief. Pleural fluid analysis revealed an exudative pattern with elevated amylase, reflecting likely pancreatic etiology, and raising suspicion of pancreaticopleural fistula (PPF). Following pleural fluid drainage and aeration of the lung, she developed fever with leukocytosis; repeat CT chest revealed multi-loculated pleural effusion. A working diagnosis of empyema secondary to (PPF) was made and patient was started on intravenous (IV) antibiotics. Magnetic resonance cholangiopancreatography (MRCP) revealed walled off necrosis surrounding the pancreatic tail extending into the left subdiaphragmatic and left pleural spaces, confirming the diagnosis of (PPF). She underwent Endoscopic retrograde cholangiopancreatography (ERCP) without successful cannulation of pancreatic duct. Partial distal pancreatectomy was performed with resolution of pleural effusion and symptoms. DISCUSSION: PPF is usually a consequence of leak from an incompletely formed or ruptured pseudocyst or from direct pancreatic duct leak either through the esophageal hiatus or the diaphragm into the pleural space. It typically presents with pulmonary symptoms more than the abdominal symptoms. Left-sided pleural effusion is typical, though right-sided or bilateral effusions are not uncommon. Empyema, a known major complication that can lead to life threatening sepsis, occurs when there is an ascending infection via the fistulous tract. Diagnosis is based on clinical suspicion; elevated amylase in pleural fluid strongly supports the diagnosis. MRCP is a useful diagnostic modality demonstrating the fistula. Initial management consists of pleural drainage and tube thoracotomy placement. Minimally invasive thoracic surgery with pleural debridement can also be considered. Definitive management of fistula is accomplished with stent placement via ERCP, though if that fails, surgical intervention with pancreatectomy is considered, as described in our case. CONCLUSIONS: A high index of clinical suspicion is needed for diagnosis of PPF in patients presenting with dyspnea and history of pancreatitis or its risk factors Reference #1: Schweigert M, Renz M, Dubecz A, Solymosi N, Ofner D, Stein HJ. Pancreaticopleural fistula-induced empyema thoracis: principles and results of surgical management. Thorac Cardiovasc Surg. 2013;61(7):619-625. doi:10.1055/s-0033-1334996 Reference #2: Machado NO. Pancreaticopleural fistula: revisited. Diagn Ther Endosc. 2012;2012:815476. doi:10.1155/2012/815476 DISCLOSURES: No relevant relationships by Ibrahim Asghar Abid, source=Web Response No relevant relationships by Lakshmi Priyanka Mahali, source=Web Response No relevant relationships by Noa Tal, source=Web Response

来院時心停止の蘇生後に偶然診断された肺癌の1例(A case of lung cancer in a patient diagnosed by chance after resuscitation of cardiopulmonary arrest on arrival)

要旨症例は76歳の男性。4日前に階段を転落した後からの左側胸部痛と呼吸苦を主訴に当院を独歩受診し，外来の廊下で突然卒倒した。目撃者により心停止を認識され，心肺蘇生を受けつつERに搬入。初期心電図波形は無脈性電気活動で，アドレナリン1mg静脈内投与と気管挿管を含む二次救命処置により自己心拍再開。蘇生後の胸部単純X線写真にて大量の左胸水貯留と縦隔右方偏位を認め，鈍的胸部外傷に伴う大量血胸と診断し，直ちに胸腔ドレナージを施行。中等度血性胸水2,100mLが排出され，バイタルサインは改善した。その後に撮影した単純CT画像にて左多発肋骨骨折を確認。ICU入室後，集中治療により意識・呼吸・循環は順調に回復し，第2病日に気管挿管チューブを抜管。第5病日に撮影した造影CT画像にて最大径46mmの左肺腫瘍と縦隔リンパ節・骨・副腎転移を認め，胸水細胞診の結果class Vと判定され，肺癌と診断。第7病日にICUを退室して呼吸器内科に転科，第64病日に神経学的後遺症なく転院となった。本症例の心停止は，癌性胸水が緩徐に貯留した状態に外傷性の血性胸水が負荷されたことにより緊張性胸水の状態となり，それまで代償性に維持し得ていた呼吸循環動態が破綻して閉塞性ショックと低酸素血症に陥ったことが原因のoncologic emergencyであったと推定された。

Edema de reexpansión pulmonar “REPE” intraoperatorio tras toracoscopia mediante ventilación unipulmonar

El “REPE” (Re-expansion Pulmonary Edema) es una complicación poco común que puede ocurrir después del drenaje rápido de un neumotórax o de abundante líquido pleural (1,2). La incidencia en adultos es del el 0-1%. Su mortalidad puede alcanzar el 20% (1,3). Las hipótesis propuestas para el desarrollo de dicha entidad incluyen, el aumento de la permeabilidad de la microvasculatura pulmonar, cambios en el flujo linfático, disminución de la producción de surfactante y aumento de la presión hidrostática del flujo vascular del pulmón reexpandido (4). Se caracteriza por el desarrollo agudo de hipoxemia refractaria al oxígeno y la aparición de infiltrados alveolares intersticiales en un plazo de 24 horas tras el drenaje (5). Son factores de riesgo de REPE: la edad comprendida entre los 20 y 40 años, la duración del colapso pulmonar mayor de 72 horas, la aplicación de altas presiones negativas durante la toracocentesis (20 cm H2O), una rápida reexpansión tras drenajes de altos volúmenes de líquido pleural (> 1.5 L) o la existencia de factores predisponentes para el edema pulmonar (hipoalbuminemia, estasis en la circulación pulmonar). ABSTRACT Intraoperative reexpansion pulmonary edema “REPE” following thoracoscopy by one lung ventilation The sudden pulmonar expansion which has remained collapsed among different hours or days, likewise the fast pneumothorax or pleural effusion drainage, can cause a flash or acute edema on the affected lung. It is believed that the rexpansive pulmonary syndrome (REPE), is caused due to an increment in the capillary permeability after being exposed the affected lung to high negative intra-pleural pressure. The ocurrence of REPE is a rare event with most cohort studies reporting an incidence of between 0%- 1%. It may extend with hypoxaemia, hypotension and even cardiac arrest. The treatment of these patients include mechanical ventilation with optimal PEEP levels, the use of vasopressors and an intesive electrolyte resuscitation. We expose the case of a 16 year old patient with mediastinal mass diagnosis and massive left-pleural effusion, where after a thorascocopy for biopsy and pleuritic drainage, it is observed a reexpansion pulmonary edema with respiratory repercussion, haemodynamics and the requirement of endotracheal reintubation.

Pericardial injury from chest compression: a case report of incidental release of cardiac tamponade

BackgroundAlthough chest compression is a standard technique in cardiopulmonary resuscitation, it is well recognized that manual chest compression causes various internal injuries, of which major injuries are often fatal. Similarly, when cardiac tamponade occurs in patients with type A acute aortic dissection, many patients die before reaching the hospital. We report a rare case in which chest compressions caused pericardial laceration that may have inadvertently played a life-saving role in releasing cardiac tamponade induced by acute aortic dissection.Case presentationA 67-year-old woman developed cardiac arrest soon after complaining of epigastric pain, and after successful resuscitation by manual chest compression, she was transferred to our hospital. On arrival, the patient was 14 on the Glasgow Coma Scale. An ECG showed a normal sinus rhythm, and no arrhythmias or signs of myocardial ischemia were observed. A chest X-ray revealed left pleural effusion, while cardiomegaly and pneumothorax were not identified. Computed tomography revealed type A aortic dissection, mild pericardial effusion, and massive left pleural effusion. No pulmonary embolus was found on the CT. After drainage of bloody effusion from the left pleural space, an emergency operation was begun. During surgery, a pericardial laceration with communication to the left pleural space and a hemothorax were found; however, no cardiac injury was identified. No other intra-thoracic injuries or rupture of the aortic dissection causing the hemothorax were detected. Hemiarch replacement was performed without difficulty, but the patient died of multi-organ failure 30 days after surgery.ConclusionsWe report a case of pericardial injury without skeletal fracture caused by chest compression. The pericardial laceration may have inadvertently served to release the cardiac tamponade induced by the acute aortic dissection, resulting in the hemothorax, and provided time to receive surgery.

Metastatic melanoma: a rare cause of central airway obstruction

A middle-aged woman with recurrent malignant melanoma presented initially with massive left pleural effusion. There was a complete obliteration of the left main bronchus on flexible bronchoscopy caused by a...

Surgical surprise in a case of loculated empyema

Cases of massive benign pleural effusion, presenting later as chronic empyema are a known entity. Surgical intervention in the form of tube thoracostomy, thoracotomy/video-assisted thoracoscopic evacuation of pus and decortication are needed as a routine. But sometimes a surgical surprise on the table, gives the tell-tale evidence of a missed aetiology for pleural effusion. We present here a rare case of chronic empyema left hemi thorax which turned out to be ruptured dermoid cyst of anterior mediastinum with massive pleural effusion which got infected on repeated thoracocentesis. A 23-year-old female, computer engineer presented with dyspnoea and dry cough of 3 months duration, associated with loss of appetite and weight. No history of fever. On examination, thin built, mild clubbing, tracheal shift to right with dullness/absent breath sounds on entire left chest. On investigation, image studies revealed massive left pleural effusion, repeated thoracocentesis done, recurrent effusion turned into pyothorax, tube thoracostomy done and empirical anti-tuberculous therapy started by chest physician. Finally, came for decortication, thoracotomy on table revealed evidence of ruptured dermoid cyst confirmed by histopathology. Patient recovered well and 6 months follow-up revealed no recurrence. Investigations did not give any clue for preoperative diagnosis in our case. Aetiology for chronic empyema is multifactorial. Ruptured anterior mediastinal benign cystic teratoma revealed on thoracotomy for empyema is a rare entity and only three cases are reported so far. We report another such rare case from south India.

A Case of Pancreaticopleural Fistula Successfully Treated with a Pancreatic Duct Stent

Pancreaticopleural fistula (PPF) is a rare complication of chronic pancreatitis. We present the case of a 34 yearsold male who presented with a massive left side pleural effusion. The MRCP showed the PPF and the patient was rapidly treated with a pancreatic duct stent. There was no recurrence of pleural effusion after twenty-two months of follow-up. This case highlights the prompt recognition of PPF by medical team and the right identification of a fistula amenable to an endoscopic treatment.

Bloody Pancreatic Pleural Effusion: A Case Report

A 54-year-old male presented with massive left bloody pleural effusion. Thoracocentasis revealed high level of amylase and lipase. The abdomen computed tomogram (CT) scan showed a pseudocyst of pancreatic tail and necrotizing pancreatitis with walled off necrosis formation that encroaching splenic vein and esophagus with upward extension to middle mediastinum and bilateral pleural effusion. The other differential diagnosis such as oesophageal perforation and certain neoplastic processes should be considered. After surgery of distal pancreatectomy with splenectomy, the symptom relieved.

Pseudomesotheliomatous carcinoma due to pleural metastasis from renal pelvic cancer.

A 78-year-old man was referred to our department with a one-week history of dyspnea and coughing. A chest X-ray showed massive left pleural effusion. Computed tomography revealed diffuse irregular thickening of the left pleura similar to malignant mesothelioma and multiple nodules in both lungs. The patient died of respiratory failure nine days after hospitalization. An autopsy revealed metastasis to the pleura and lungs from urothelial carcinoma of the left kidney.

Heart Failure due to Tension Hydrothorax after Left Pneumonectomy

Tension hydrothorax is a rare complication of pneumonectomy for pleural mesothelioma and an exceptionally rare cause of heart failure. We describe a patient who had undergone extrapleural pneumonectomy, chemotherapy, and radiation for pleural mesothelioma and who developed heart failure symptoms within months of the completion of treatment. Investigation showed a massive left pleural effusion resulting in tension hydrothorax, mediastinal shift, and evidence of right heart failure with constrictive physiology and low cardiac output. Therapeutic thoracentesis resulted in increase in cardiac output and symptomatic improvement.

Massive mediastinal teratoma mimicking pleural effusion on computed tomography

Mediastinal teratomas have been reported to mimic pleural effusions on chest radiography. Further evaluation of such tumours using computed tomography usually yields diagnostic characteristics that distinguish them from pleural collections. We report a patient with a mediastinal teratoma that mimicked a massive left pleural effusion on chest radiography and computed tomography.

An extremely rare case of small-cell lung cancer harboring variant 2 of the EML4-ALK fusion gene

Anaplastic lymphoma kinase (ALK) fuses echinoderm microtubule-associated protein-like 4 (EML4) to acquire a transforming activity in lung adenocarcinomas. However, the presence of an EML4-ALK fusion gene in other lung cancer histologies is an extremely rare phenomenon. A 43-year-old female was referred to our department due to dyspnea on effort and left back pain. Computed tomography (CT) showed a large mass in the upper lobe of the left lung and a massive left pleural effusion, while a CT-guided needle biopsy confirmed a diagnosis of small-cell lung cancer (SCLC). Surprisingly, the tumor was genetically considered to harbor the EML4-ALK fusion gene (variant 2). Although the patient underwent two regimens of cytotoxic chemotherapy for SCLC, she died approximately seven months after the administration of first-line chemotherapy. Our analysis of 30 consecutive patients with SCLC for EML4-ALK revealed that two patients, including the current patient and a patient we previously reported, harbored the EML4-ALK fusion gene.

Intrathoracic gastric perforation: a late complication of an unknown postpartum recurrent hiatal hernia

Diaphragmatic hernias occurring during pregnancy are an uncommon event. In very rare occasions, the clinical situation can suddenly worsen due to obstruction, torsion or infarction of the herniated viscera. Here, we describe a challenging case of a post-partum diaphragmatic hiatus hernia complicated by intrathoracic gastric perforation. A 23-year old woman was admitted at our hospital with a syndrome characterized by epigastralgy, dyspnoea and fever. She had previously undergone a laparoscopic antireflux surgery for hiatus hernia (6 years before) and a recent (4 months) unremarkable vaginal delivery. Due to the persistence of a pelvic pain after the delivery, she had been taking pain-killers as a self-administered medication. A CT scan showed a massive left pleural effusion and a complete herniation of the stomach into the left hemithorax. After placing a chest drainage and removing up to 3000ml of brownish purulent fluid, a repeat CT scan (with water soluble contrast swallow) showed a leak at the level of the stomach. At surgery, we observed a complete intrathoracic herniation through a large diaphragmatic hiatal defect and a small well-defined gastric ulcer. A primary repair of both the stomach and the diaphragm was performed. We take the opportunity presented by this report to briefly discuss the patho-physiological mechanisms underlying this unusual complication.